Updated guidelines for treatment of blood cholesterol were recently published in the American Heart Association medical journal, Circulation. Full guidelines were last issued in 2002, so there was tremendous interest among doctors waiting for new recommendations about treating patients with cholesterol issues.

Elevated blood cholesterol is an important risk factor leading to plaque developing in arteries. Having doctors know about the most up-to-date treatment of high cholesterol is vitally important to help patients at high risk for heart attack and stroke.

What will the impact be on treatment decisions, particularly those considered high risk? Patient should ask their doctors what effect these guidelines may have on his or her approach to existing cholesterol treatment.

A 2002 report, updated partially in 2004, was the last full set of instructions for physicians. These recommendations were based on clinical studies of patients treated with cholesterol-lowering drugs, particularly statins such as Lipitor or Zocor.

That report strongly advised physicians to lower LDL (or “bad”) cholesterol levels in high-risk patients to 70 mg/dl or below, primarily with statin drugs. LDL is the most common form of cholesterol causing artery blockage. Statins were chosen as the first-line drugs because of their effectiveness.

The new report surprisingly did away with LDL target numbers, instead recommending LDL be reduced by 50 percent or greater, primarily with statins. It also introduced a new risk score that measures patients’ other risk factors and produces a percent risk of a heart attack within 10 years. Who would need a 50 percent or greater reduction in their LDL? High-risk people in four groups:

1. Those with known heart disease.

2. Diabetics with or without heart disease.

3. Patients with a 7.5 percent or greater 10-year chance of a heart attack.

4. Low-risk patients with very high total cholesterol.

The panel did not dismiss LDL levels. It remains an important risk factor for heart disease and a benchmark to measure patient compliance with their treatment. LDL will continue to be routinely monitored by doctors.

Strategy seeks to avoid overtreatment

The decision to eliminate specific target numbers in favor of percent reduction was based on the fact that the earlier goals were never the primary end point of any clinical study. While the “lower the better” theory regarding bad cholesterol may be generally true, a well-treated patient with an LDL level of 78 mg/dl may be at lower risk than a less well-treated patient with an LDL of 68 mg/dl.

The panel reinforced that it is extremely important to address and control other cardiac risk factors, such as smoking and high blood pressure, in addition to cholesterol. In addition, “chasing” cholesterol target numbers may lead to overtreatment with medication, possibly causing unwanted side effects.

The new guidelines have prompted a fast and furious reaction from the medical community. Supporters praise what they feel is a simpler approach to cholesterol reduction as well as a better organization of high-risk patient groups. More patients who may benefit from statin drugs will be prescribed them, while patients at lower risk can avoid taking them.

Critics are concerned about the reliability of the new risk score and the potential risks of the high doses of statins needed to achieve the recommended 50 percent reduction.

As a St. Luke’s cardiologist specializing in the treatment of cholesterol disorders, I admit my surprise at the new report. Specific target numbers have been in place for 25 years. Changing longstanding practice patterns, particularly for busy family doctors, may cause confusion, making them hesitant to fully adopt the new guidelines. Yet much of what we do as physicians does not change. Treatment for high-risk patients nearly always requires lowering LDL cholesterol by 50 percent to meet even the previous recommendations. The majority of current treatment centers on statins, adding other agents only when needed to achieve this aggressive goal.

I do not disagree with the basic principles of the new report. There is no doubt many high-risk patents should be taking statins. I support the proposals and believe they will result in more people being appropriately treated.

What does it mean for those with heart disease? If you are at high risk, little will probably change. By all means, discuss these new recommendations with your physicians.

People will read different and perhaps critical opinions of this report in the coming months. Remember. though, the ultimate goal — by significantly lowering cholesterol, having a healthy, active lifestyle and managing other risk factors — is to reduce the impact of cardiovascular disease on the long-term health of patients. This is a goal of patient treatment that will never change.

Gerald E. Pytlewski is associate chief of cardiology at St. Luke’s University Health Network and a diplomate of the American Board of Clinical Lipidol